Quantifying uptake and completion of pulmonary rehabilitation programs in people with chronic obstructive pulmonary disease known to tertiary care

Background People with symptomatic chronic obstructive pulmonary disease (COPD) benefit from pulmonary rehabilitation programs (PRPs), but program attrition is common. Methods For people with COPD who presented to tertiary care and appeared appropriate for a PRP, we prospectively mapped their PRP journey, explored factors influencing attendance to pre-program assessment and captured program attrition. Results Of the 391 participants, 31% (95% CI 27 to 36) were referred to a PRP (n = 123; age 68 ± 10years, 62 males [50%], FEV1 45 ± 19%predicted). Of those referred, 94 (76% [69 to 84]) attended a pre-program assessment. Ex-smokers and those who had a healthcare professional (HCP) explain they would be referred were more likely to attend a pre-program assessment (odds ratio [95%CI]; 2.6 [1.1 to 6.1]; and 4.7 [1.9 to 11.7], respectively). Of the 94 who attended, 63 (67% [58 to 77]) commenced; and of those who commenced, 35 (56% [43 to 68]) completed a PRP. All who completed (n = 35, 100%) were provided at least one strategy to maintain training-related gains. Conclusion Attrition occurs throughout the PRP journey. Interactions with HCPs about PRPs positively influenced attendance. Understanding how HCPs can best contextualise PRPs to encourage referral acceptance and uptake is an important area for further work.


Supplementary material
Data reported in this prospective observational study (i.e.horizon scan) were collected as part of a larger mixed-methods study. 1 The purpose of the larger study is to optimise the implementation and utilisation of pulmonary rehabilitation programs (PRPs) for people with COPD known to tertiary care in Perth, Western Australia (WA).Further information for this study can be found at our project page on the Open Science Framework (OSF); https://osf.io/qet25/.

Inclusion criteria
People with COPD were sequentially recruited from the Respiratory in-patient and out-patient areas of three tertiary hospitals in Perth, WA between August 2020 and January 2021.The inclusion and exclusion criteria for this horizon scan study were designed to find people likely to be appropriate for referral to a physiotherapist-led PRP conducted in either a hospital out-patient department or community centre.That is, participants were required to have a diagnosis of COPD, be English speaking, be independently ambulant and have a life expectancy of more than six months.
Potential participants were excluded if they were living in supported residential aged care or had a cognitive impairment.Those recruited as out-patients were excluded if they had participated in either a PRP within the previous 12 months, or a 'maintenance' PRP within the previous 8 weeks.Of those who consented to the larger study, those referred to a face-to-face group-based PRP during the five-month recruitment period were included in this study.

Grouping of participants
Data pertaining to referral behaviours has been published separately. 2 In this previous study which reported referral behaviours, 2 the research team utilised pragmatic criteria to group participants according to their suitability for a referral to a PRP.These criteria were based on the participant having symptoms limiting their physical activity and no comorbidities precluding safety during exercise, which is appropriate for PRP service delivery in Perth, WA.The research aim for the previous study was to understand what proportion of people with COPD who are receiving specialist care through a tertiary hospital and appear suitable for referral to a centrebased PRP went on to be referred within two weeks of hospital discharge or outpatient appointment. 2Grouping according to suitability for a referral to a PRP enabled us to understand which participant referrals had been missed (which is the implementation gap) and which participants were appropriately not referred.In the current analyses, the research aim was, among those who were referred to a PRP (regardless of their suitability of the program), to quantify the proportion who went on to attend a pre-program assessment, commence and complete a PRP.We therefore did not apply the suitability grading.Further, any participant who was referred to a PRP at any time during the five-month recruitment period was included in study analyses.

Data collection
Recruitment and data collection were completed by research officers, all of whom were qualified Physiotherapists, with at least 10 years of clinical experience (either within Respiratory Medicine or specific to a PRP).Research officers received standardised training for interviewing participants and were given strict instruction to observe and interact with participants only.Data for initial recruitment were collected from the medical records and via an interview with the participant using REDCap data collection tools (available at our OSF webpage).Once recruited, data regarding the journey from point of referral, through to attendance at pre-program assessment, program commencement and program completion (including the provision of strategies for program maintenance) were prospectively tracked by the first author via discussion with the PRP physiotherapist and/or participant and reviewing the medical records.If a participant did not attend, commence or complete a PRP, reasons for attrition were sought from the participant and/or treating physiotherapist, and recorded in our REDCap data collection tools.The aim of this study was to observe and quantify current clinical practice of PRPs across WA.Therefore PRP prescription and program completion was determined by the treating physiotherapist, the study reported on these data.

Exploring the interaction with a healthcare professional
During the initial recruitment interview, the research officer asked the participant the following question: 1. Did a healthcare professional explain to you that you will be referred to a pulmonary rehabilitation program (exercise classes for people with lung problems)?If a participant was not offered a referral to a PRP or did not recall a healthcare professional offering them a referral to a PRP, this question was marked as 'no' or 'unable to determine' respectively.If the participant recalled being referred to a PRP, they were asked to complete the following: 2. Please rate the level of enthusiasm with which the healthcare profession (who spoke with you about the referral) talk about the rehabilitation program (where 0 means no enthusiasm and 100 means the highest possible enthusiasm) (graded using a 0 to 100 Visual Analogue Scale [VAS] 3 ).These requests were read by the research officer verbatim and were asked after the interaction with the healthcare professional.

Data analysis
The variables which were included in the analyses for this study were purposefully selected by the research team through clinical judgement.These variables were easily measured by clinicians, and if found to differ between groups, could be used to inform clinical practice and potentially improve engagement with PRPs.
As this study was exploratory (rather than hypothesis-testing) no formal sample size calculations were undertaken.It is important to note that we would have liked to undertake similar analyses to explore factors influencing whether or not a participant commenced, and completed a PRP, however significant attrition limited our capacity to do so.

a pre-program assessment 
Fig.1